Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS ...Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.
Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.
Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).
Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
Leaders of critical care services require knowledge and skills not typically acquired during their medical education and training. Leaders possess personality characteristics and evolve and adopt ...behaviors and knowledge in addition to those useful in the care of patients and rounding with an ICU team. Successful leaders have impeccable integrity, possess a service mentality, are decisive, and speak the truth consistently and accurately. Effective leaders are thoughtful listeners, introspective, develop a range of relationships, and nurture others. They understand group psychology, observe, analyze assumptions, decide, and improve the system of care and the performance of their team members. A leader learns to facilely adapt to circumstance, generate new ideas, and be a catalyst of change. Those most successful further their education as a leader and learn when and where to seek mentorship. Leaders understand their organization and its operational complexities. Leaders learn to participate and knowledgeably contribute to the fiscal aspects of income, expense, budget, and contracts from an institutional and department perspective. Clinician compensation must be commensurate with expectations and be written to motivate and make clear duties that are clinical and nonclinical. A leader understands and plans to address the evolving challenges facing healthcare, especially resource constraints, the emotions and requirements of managing the end of life, the complexities of competing demands and motivations, the bureaucracy of healthcare practice, and reimbursement. Responsibilities to manage and evolve must be met with intelligence, sensitivity, and equanimity.
Leaders of critical care programs have significant responsibility to develop and maintain a system of intensive care. At inception, those clinician resources necessary to provide and be available for ...the expected range of patient illness and injury and throughput are determined. Simultaneously, non-ICU clinical responsibilities and other expectations, such as education of trainees and participation in hospital operations, must be understood. To meet these responsibilities, physicians must be recruited, mentored, and retained. The physician leader may have similar responsibilities for nonphysician practitioners. In concert with other critical care leaders, the service adopts a model of care and assembles an ICU team of physicians, nurses, nonphysician providers, respiratory therapists, and others to provide clinical services. Besides clinician resources, leaders must assure that services such as radiology, pharmacy, the laboratory, and information services are positioned to support the complexities of ICU care. Metrics are developed to report success in meeting process and outcomes goals. Leaders evolve the system of care by reassessing and modifying practice patterns to continually improve safety, efficacy, and efficiency. Major emphasis is placed on the importance of continuity, consistency, and communication by expecting practitioners to adopt similar practices and patterns. Services anticipate and adapt to evolving expectations and resource availability. Effective services will result when skilled practitioners support one another and ascribe to a service philosophy of care.
Intensive care units (ICUs) face financial, bed management, and staffing constraints. Detailed data covering all aspects of patients' journeys into and through intensive care are now collected and ...stored in electronic health records: machine learning has been used to analyse such data in order to provide decision support to clinicians.
Systematic review of the applications of machine learning to routinely collected ICU data. Web of Science and MEDLINE databases were searched to identify candidate articles: those on image processing were excluded. The study aim, the type of machine learning used, the size of dataset analysed, whether and how the model was validated, and measures of predictive accuracy were extracted.
Of 2450 papers identified, 258 fulfilled eligibility criteria. The most common study aims were predicting complications (77 papers 29.8% of studies), predicting mortality (70 27.1%), improving prognostic models (43 16.7%), and classifying sub-populations (29 11.2%). Median sample size was 488 (IQR 108-4099): 41 studies analysed data on > 10,000 patients. Analyses focused on 169 (65.5%) papers that used machine learning to predict complications, mortality, length of stay, or improvement of health. Predictions were validated in 161 (95.2%) of these studies: the area under the ROC curve (AUC) was reported by 97 (60.2%) but only 10 (6.2%) validated predictions using independent data. The median AUC was 0.83 in studies of 1000-10,000 patients, rising to 0.94 in studies of > 100,000 patients. The most common machine learning methods were neural networks (72 studies 42.6%), support vector machines (40 23.7%), and classification/decision trees (34 20.1%). Since 2015 (125 studies 48.4%), the most common methods were support vector machines (37 studies 29.6%) and random forests (29 23.2%).
The rate of publication of studies using machine learning to analyse routinely collected ICU data is increasing rapidly. The sample sizes used in many published studies are too small to exploit the potential of these methods. Methodological and reporting guidelines are needed, particularly with regard to the choice of method and validation of predictions, to increase confidence in reported findings and aid in translating findings towards routine use in clinical practice.
OBJECTIVE:Early mobility in mechanically ventilated patients is safe, feasible, and may improve functional outcomes. We sought to determine the prevalence and character of mobility for ICU patients ...with acute respiratory failure in U.S. ICUs.
DESIGN:Two-day cross-sectional point prevalence study.
SETTING:Forty-two ICUs across 17 Acute Respiratory Distress Syndrome Network hospitals.
PATIENTS:Adult patients (≥ 18 yr old) with acute respiratory failure requiring mechanical ventilation.
INTERVENTIONS:We defined therapist-provided mobility as the proportion of patient-days with any physical or occupational therapy–provided mobility event. Hierarchical regression models were used to identify predictors of out-of-bed mobility.
MEASUREMENTS AND MAIN RESULTS:Hospitals contributed 770 patient-days of data. Patients received mechanical ventilation on 73% of the patient-days mostly (n = 432; 56%) ventilated via an endotracheal tube. The prevalence of physical therapy/occupational therapy–provided mobility was 32% (247/770), with a significantly higher proportion of nonmechanically ventilated patients receiving physical therapy/occupational therapy (48% vs 26%; p ≤ 0.001). Patients on mechanical ventilation achieved out-of-bed mobility on 16% (n = 90) of the total patient-days. Physical therapy/occupational therapy involvement in mobility events was strongly associated with progression to out-of-bed mobility (odds ratio, 29.1; CI, 15.1–56.3; p ≤ 0.001). Presence of an endotracheal tube and delirium were negatively associated with out-of-bed mobility.
CONCLUSIONS:In a cohort of hospitals caring for acute respiratory failure patients, physical therapy/occupational therapy–provided mobility was infrequent. Physical therapy/occupational therapy involvement in mobility was strongly predictive of achieving greater mobility levels in patients with respiratory failure. Mechanical ventilation via an endotracheal tube and delirium are important predictors of mobility progression.
The optimization of intensive care unit (ICU) care impacts clinical outcomes and resource utilization. In 2017, our surgical ICU (SICU) adopted a “closed-collaborative” model. The aim of this study ...is to compare patient outcomes in the closed-collaborative model versus the previous open model in a cohort of trauma surgical patients admitted to our adult level 1 trauma center.
A retrospective review of trauma patients in the SICU from August 1, 2015 to July 31, 2019 was performed. Patients were divided into those admitted prior to August 1, 2017 (the “open” cohort) and those admitted after August 1, 2017 (the “closed-collaborative” cohort). Demographic variables and clinical outcomes were analyzed. Trauma severity was assessed using injury severity score (ISS).
We identified 1669 patients (O: 895; C: 774). While no differences in demographics were observed, the closed-collaborative cohort had a higher overall ISS (O: 21.5 ± 12.14; C: 25.10 ± 2.72; P < 0.0001). There were no significant differences between the two cohorts in the incidence of strokes (O: 1.90%; C: 2.58%, P = 0.3435), pulmonary embolism (O: 0.78%; C: 0.65%; P = 0.7427), sepsis (O: 5.25%; C: 7.49%; P = 0.0599), median ICU charges (O: $7784.50; C: $8986.53; P = 0.5286), mortality (O: 11.40%; C: 13.18%; P = 0.2678), or ICU length of stay (LOS) (O: 4.85 ± 6.23; C: 4.37 ± 4.94; P = 0.0795).
Patients in the closed-collaborative cohort had similar clinical outcomes despite having a sicker cohort of patients. We hypothesize that the closed-collaborative ICU model was able to maintain equivalent outcomes due to the dedicated multidisciplinary critical care team caring for these patients. Further research is warranted to determine the optimal model of ICU care for trauma patients.
•Impact of surgical ICU modeling on trauma surgical patient outcomes.•Compared to an open model, a closed-collaborative SICU model provides.oEquivalent care (mortality and complications) despite having sicker patients.oSignificant reduction in ICU LOS in the sickest cohort of patients (ISS ≥15).oNonstatistically significant reduction in ICU charges in the sickest cohort of patients (ISS ≥15).
In the recent years, digital intensive care unit (ICU) diaries have emerged as more advantageous than paper diaries. Despite the advantages of digital diaries, the successful implementation and ...maintenance of this digital intervention present significant challenges in clinical practice. Therefore, understanding the facilitators and barriers among stakeholders influencing this process becomes imperative for devising a tailored strategy to integrate digital diaries effectively within ICU settings.
The aim of this study was to explore facilitators and barriers for implementation of a digital ICU diary from the perspectives of ICU professionals, ICU survivors, and their relatives.
A qualitative design was used, incorporating focus-group interviews with professionals from four Dutch ICUs, along with individual interviews with ICU survivors and relatives. The study spanned from October 2022 to April 2023. Data analysis utilised a mixed inductive–deductive approach, particularly through directed content analysis. The Consolidated Framework for Implementation Research 2.0 guided both data collection and analysis processes.
We conducted five focus-group interviews among ICU professionals (n = 32) and 10 individual or dual interviews involving five ICU survivors and nine relatives. Key facilitators for implementing a digital diary according to ICU professionals encompassed a user-friendly interface accessible independent of time and place, with a seamless login process requiring minimal steps, comprehensive training covering all aspects of its use, and feedback from the experiences of both patients and relatives. Barriers for ICU professionals included many steps required to access the digital diary, as well as resistance to (co)writing diary entries. In contrast, professionals’ involvement in writing diary entries was highly appreciated among ICU survivors and relatives. An ambiguous factor arose regarding sharing the digital diary with others; both ICU survivors and relatives found it valuable, yet it also raised privacy concerns.
This study offers insights into the most important factors influencing the implementation of a digital ICU diary. Strikingly, some factors serve as both barriers and facilitators. When developing the implementation strategy, the identified facilitators can be used to overcome the barriers faced by ICU professionals, ICU survivors, and their relatives in adopting a digital diary.
OBJECTIVES:Coronavirus disease 2019 patients are currently overwhelming the world’s healthcare systems. This article provides practical guidance to front-line physicians forced to make critical ...rationing decisions.
DATA SOURCES:PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies.
STUDY SELECTION:Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email.
DATA EXTRACTION:References and data were based on relevance and author consensus.
DATA SYNTHESIS:We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. “First come, first served” is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categoriesperformance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients.
CONCLUSIONS:Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.
A decrease in disease-specific mortality over the last twenty years has been reported for patients admitted to United States (US) hospitals, but data for intensive care patients are lacking. The aim ...of this study was to describe changes in hospital mortality and case-mix using clinical data for patients admitted to multiple US ICUs over the last 24 years.
We carried out a retrospective time series analysis of hospital mortality using clinical data collected from 1988 to 2012. We also examined the impact of ICU admission diagnosis and other clinical characteristics on mortality over time. The potential impact of hospital discharge destination on mortality was also assessed using data from 2001 to 2012.
For 482,601 ICU admissions there was a 35% relative decrease in mortality from 1988 to 2012 despite an increase in age and severity of illness. This decrease varied greatly by diagnosis. Mortality fell by >60% for patients with chronic obstructive pulmonary disease, seizures and surgery for aortic dissection and subarachnoid hemorrhage. Mortality fell by 51% to 59% for six diagnoses, 41% to 50% for seven diagnoses, and 10% to 40% for seven diagnoses. The decrease in mortality from 2001 to 2012 was accompanied by an increase in discharge to post-acute care facilities and a decrease in discharge to home.
Hospital mortality for patients admitted to US ICUs has decreased significantly over the past two decades despite an increase in the severity of illness. Decreases in mortality were diagnosis specific and appear attributable to improvements in the quality of care, but changes in discharge destination and other confounders may also be responsible.
Aim
To systematically evaluate the effect of intensive care unit diary psychotherapy on the incidence of posttraumatic stress disorder, anxiety, and depression after discharge from intensive care ...unit.
Background
Many studies have reported the potential advantages and risks of intensive care unit diary psychotherapy in adult patients discharged from intensive care unit, but the results are divergent.
Design
Systematic review and meta‐analysis of prospective randomized controlled or case‐controlled studies.
Data source
Databases such as Cochran Library, Pubmed, Embase, CINAHL, and ProQuest databases, China national knowledge infrastructure (CNKI) were searched for literatures published from January 2000–March 2020.
Review methods
We use the Cochrane Risk of Bias Tool for quality assessment and audit manager 5.3 software for meta‐analysis. The main result is the incidence of posttraumatic stress disorder, anxiety, and depression.
Results
Ten studies meeting the inclusion criteria were identified, including eight randomized controlled studies and two case‐controlled studies, with a total of 1,210 patients. The pooled results of this meta‐analysis indicated that the intensive care unit diary could reduce the incidence of posttraumatic stress disorder, anxiety, and depression.
Conclusion
This study showed that an intensive care unit diary could improve the psychological symptoms of adult intensive care unit patients after discharge. However, due to limitations such as publication bias and case sample size, the results should be carefully considered. Researchers need to further clarify the multidisciplinary collaborative process of intensive care unit diary therapy, the real beneficiaries, and its impact on family members' psychological status by conducting large, robust studies in the future.
Impact
This study's findings suggest that medical staff need to re‐examine the role of intensive care unit diary therapy, its standardized implementation and provide effective intervention for reducing psychological stress‐related symptoms of intensive care unit patients after discharge.
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